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EtoH Withdrawal: The Latest Science and Medical Techniques to Safely Manage Alcohol Detoxification

EtoH Withdrawal: The Latest Science and Medical Techniques to Safely Manage Alcohol Detoxification

Ethanol – medically abbreviated as EtOH and also known as drinking alcohol – is a severely-addictive substance that, when chronically and heavily abused, causes profound changes in the physical and chemical structure of the brain. Consequently, alcohol rehabilitation and detoxification must be closely supervised to be either safe or effective.

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Why Is Quitting Alcohol So Dangerous?

Over time, the user’s brain becomes accustomed to the presence of EtOH and adapts. As a result, the person becomes physically dependent on alcohol. In other words, they lose the ability to even nominally function when they aren’t under the influence of alcohol. When they stop drinking abruptly, their body basically goes into “shock” as their alcohol-dependent brain attempts to rebound and compensate for the lack of ethanol. This results in a number of painful, unpleasant, dangerous, and even deadly withdrawal symptoms. Alcohol withdrawal symptoms can be extremely serious, resulting in the disruption of the body’s autonomic functions and central nervous system. The alcoholic’s brain becomes “hyperexcitable”, because receptors that WERE chronically inhibited by alcohol consumption are no longer inhibited. Roughly half of all alcoholics experience withdrawal when they quit drinking. The symptoms can manifest in just a few hours after the last drink, and typically last 2-4 days. In extreme cases, however, alcohol withdrawal can persist for over a week. The timing and the severity of symptoms greatly depend on the person’s personal drinking history. The longer and heavier the person has abused alcohol, the faster the onset of symptoms and the more dangerous those symptoms become. Let’s take a look at an alcohol withdrawal timeline.

Minor Alcohol Withdrawal Symptoms (6-36 hours from the last drink)

At first, most alcohol withdrawal symptoms are relatively minor. While unpleasant, they are not particularly dangerous.

  • Mild anxiety
  • Agitation
  • Irritability
  • Headache
  • Sensitivity to light and sound
  • Profuse sweating
  • Tremors, especially in the hands, eyelids, and tongue
  • Insomnia
  • Palpitations
  • Nausea
  • Vomiting
  • Diarrhea

It is important to note that these minor symptoms can persist for up to 6 months.

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Alcoholic Hallucinosis (12-48 hours)

Also called alcohol-related psychosis, this is a complication typically suffered by chronic alcoholics with a long history of severe and heavy drinking – about 20% of hospitalized alcoholics. Particularly identified by the rapid onset, these hallucinations are most frequently visual, although they can also be auditory or tactile. Unlike someone suffering from more serious delirium tremens, a person at this stage will still be aware of reality. A popular euphemism mentions how hallucinating alcoholics see “pink elephants”. Typically, alcoholic hallucinosis temporary subsides within 48 hours, before the onset of more serious and dangerous withdrawal symptoms.

Alcohol Withdrawal Seizures (2-48 hours)

This stage usually begins within 12 hours following the last drink, although severe alcoholics can suffer a seizure in as little as 2 hours. A person at this stage will typically suffer a single seizure or, less commonly, a brief episode of several seizures. These are tonic-clonic incidences:

  • Tonic – Generally, the person loses consciousness during this phase of the seizure. Then their muscles become extremely rigid. If they were standing or sitting at the start of the episode, there is a risk of injury due to falling.
  • Clonic – This phase of the seizure is marked by uncontrollable jerking and convulsions. Often, the person will bite or crush their tongue because of the strong, muscular contractions. Sometimes, the person will lose control of their bladder or bowels.

A tonic-clonic seizure is exhausting, and the person may remain unconscious for several minutes. Following the episode, the person will also experience temporary confusion and total amnesia. Of special relevance, without treatment, one-third of alcoholics who have reached this point will progress to the most dangerous state of alcohol withdrawal – delirium tremens.

Delirium Tremens (48-96 hours)

This is the most dangerous stage of alcohol withdrawal syndrome. Without treatment, up to 40% of patients will die. Even with treatment, the mortality rate is as high as 15%. Also known as the “DTs” or the “drunken horrors”, delirium tremens is most common among alcoholics with a long personal history of alcohol abuse lasting 10 years or more. Older drinkers and individuals who have previously experienced alcohol withdrawal are also at greater risk. The symptoms of delirium tremens manifest rapidly, typically presenting 23 days following the last drink, although instances of delayed onsets of up to 10 days have been reported. Severity peaks approximately 2 days after symptoms begin. Symptoms of delirium tremens include:

  • Shivering
  • Shaking
  • Autonomic instability
  • Irregular heartbeat
  • Tachycardia
  • High blood pressure
  • Extreme fever
  • Profuse sweating
  • Seizures
  • Confusion
  • Disorientation
  • Panic attacks – to the point of terror
  • Paranoia
  • Terrifying nightmares
  • Hallucinations – to the point of being disconnected from reality
  • Perceptual disturbances
  • A sensation that insects are crawling on or under the skin
  • An overpowering sense of impending doom or death

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Kindling – The Dangers of Multiple Detoxifications

When a person engages in a repeated cycle of alcohol abuse – binge drinking, for example – followed by period of abstinence, they become overly-sensitive to alcohol withdrawal. This means that the withdrawal symptoms they experience will gradually intensify. This phenomenon, known as kindling, can permanently alter the brain’s chemistry, resulting in:

  • Worsened withdrawal symptoms
  • Brain damage
  • Memory impairment
  • Cognitive decline

In fact, 48% of alcoholics who suffer seizures during inpatient alcohol detox have a personal history of at least 5 previous withdrawal episodes. Conversely, just 12% of those alcoholics with such a history experience no seizures. Because kindling eventually exacerbates the symptoms of alcohol withdrawal, this makes it extremely important to properly and aggressively address even mild symptoms to prevent the possibility of subsequent withdrawal episodes. Alcohol withdrawal should not be viewed as an isolated event. Rather, it is part of an often long-term process that worsens with every subsequent episode.×341.jpg

Post-Acute Withdrawal Syndrome (PAWS)

For up to two years after alcohol detoxification, a person can still experience a set of negative symptoms that can complicate successful recovery:

  • Cravings
  • Wild mood swings – either outbursts or a pronounced lack of emotion
  • Heightened anxiety
  • Depression
  • Irritability
  • Vulnerability to stress
  • Lack of motivation
  • Low energy
  • Inability to derive pleasure from previously-enjoyed activities – hobbies, social interaction, sex, etc.
  • Feelings of guilt
  • Obsessive-compulsive behavior
  • Insomnia and poor sleep
  • Disturbing dreams – particularly of resumed drinking
  • Memory problems
  • Decision-making difficulty
  • Dizziness
  • Balance problems
  • Clumsiness
  • Increased pain sensitivity

Of special note, PAWS is episodic. Symptoms can manifest with no warning, and persist for 2-3 days at a time. This is why it is so important for alcoholics in recovery to receive treatment and have long-term support following alcohol detoxification.

How Is Alcohol Withdrawal Syndrome Treated?

For the minor symptoms of alcohol withdrawal, most of the focus is on making the patient as comfortable as possible. Treatment in a residential detox facility may include:

  • A comfortable bed
  • Controlled temperature
  • Subdued lighting
  • Rehydration
  • Vitamin and mineral replacement—magnesium, folic acid, thiamine, phosphate, sodium, and multivitamin supplements.

The most commonly-employed pharmacological method of treating alcohol withdrawal is through the use of sedating benzodiazepines:

  • Chlordiazepoxide (Librium)
  • Diazepam (Valium)
  • Lorazepam (Ativan)
  • Oxazepam (Serax)

Typically, a standard dose is given every 30 minutes, until the patient is sedated. Once the baseline is established, the benzodiazepine is gradually tapered over the following 3 to 10 days. Because alcohol withdrawal is an excitation of the autonomic nervous systems, adrenergic medications are particularly helpful at lowering pulse and blood pressure. Non-sedating anti-seizure medications are sometimes considered a preferred option because they:

  • Decrease the possibility of a dangerous seizure.
  • Block kindling.
  • Do not have a potential for abuse, unlike benzodiazepines.
  • Also help with mood and anxiety disorders, both of which commonly co-occur with alcohol abuse.
  • Are not as sedating as benzodiazepines, allowing the patient to more quickly engage in alcohol treatment.

Although it is not yet a common practice in the United States, doctors in Europe have long used the anticonvulsant medications valproic acid (Depakote) and carbamazepine (Tegretol) successfully to treat alcohol withdrawal syndrome. Clinical studies have concluded that atenolol helps in stabilizing vital signs and curving abnormal behaviors during alcohol withdrawal. Clonidine helps patients recover faster. In particular, clonidine helps with:

  • Tremors
  • Tension
  • Elevated blood pressure
  • Anxiety
  • Depression
  • Excessive sweating

Benzodiazepines remain the preferred option for the treatment of delirium tremens, although low doses of antipsychotics – primarily haloperidol (Haldol) are sometimes used.×282.jpg

What Are the Goals of Alcohol Detox?

Alcohol detox should have 2 main goals:

  • To provide the patient with an environment in which to quit alcohol that is as safe and comfortable as possible.
  • To prepare the patient for alcohol rehab.

Some people wonder about the necessity of the second goal. It is important to keep in mind that detox is not recovery. Although alcoholism IS a disease of the brain characterized by chemical changes, it is ALSO a psychosocial condition, influenced by numerous factors, such as:

  • Poor coping skills
  • Peer pressure
  • Triggers – people, places, things, and emotions associated with drinking
  • Stress
  • Co-occurring mental disorders – anxiety, depression, PTSD, etc.

If these other factors are not addressed, it is extremely easy to relapse and return to problematic drinking. One can also not disregard the prolonged symptoms associated with PAWS. Without the structure and support provided and taught during alcohol rehab, a person can resume drinking in an attempt to alleviate uncomfortable symptoms.

If Alcohol Detox Is Not Recovery, Why Is It Necessary?

While alcohol detox does not give you the tools to implement the changes in attitude and behavior needed to manage your addiction, it DOES provide you with the absolutely-critical foundation of physical sobriety. All of the psychological and behavioral aspects of alcohol rehab – the individual counseling, peer group therapy, education, lifestyle changes, continuing support – cannot be effective while you are still physically addicted to alcohol. Once freed from the physical aspects of alcohol addiction, you will be better able to receive the messages and lessons of total sobriety – physical AND emotional.×432.jpg

Can Alcohol Detox Be Done at Home?

FIRST – If a person is truly addicted to alcohol, it is extremely unlikely that they will be able to stop drinking on their own. Most people with Alcohol Use Disorders make numerous attempts to quit drinking or at least cut back. And, without outside help, these attempts are almost always unsuccessful. This is one of the defining characteristics of an addiction. A “persistent desire or unsuccessful efforts to cut down or control substance use” is defined by the DSM-5, the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders, as one of the main criteria necessary for a medical diagnosis of an AUD. SECOND – Most alcohol abusers also misuse other intoxicants – illicit drugs, prescription medications, etc. Trying to detox from multiple substances at once is too hard for most people. THIRD – Because severe alcohol withdrawal can be dangerous, it is definitely NOT recommended that ANYONE try to abruptly quit alcohol “cold turkey” on their own. For example, someone detoxing at home does not have the resources to address medical emergencies such as alcohol-related seizures or the rapid onset of delirium tremens.

The Benefits of Residential Alcohol Detox

Inpatient alcohol detoxification provides a number of benefits that cannot be realized during a self-detox:

  • Safety – Detox staff have the training and experience necessary to prevent and respond to withdrawal-related emergencies.
  • Prescription medications – From easing discomfort to regulating bodily functions to preventing dangerous seizures, residential alcohol detox programs can provide the proper medication to properly treat the problem.
  • Complete care – Detox facilities have the resources to help you detox from multiple substances simultaneously.
  • Freedom from outside triggers and temptations – A residential alcohol detox facility is a safe, monitored environment that separates patients from the opportunity to drink.
  • No distractions – While in the detox facility, a person’s only focus is on overcoming their physical dependence on alcohol.
  • Easier transition to treatment – Most alcohol detox programs have a reciprocal association with local alcohol rehabs. There is no waiting list or other delay.×699.jpg

Predicting the Future by Looking at Past Behaviors

If you have previously tried – and failed – to quit drinking on your own, there are a number of reasons why you may have a greater need for professional alcohol detox this time: First – if you suffered any complications due to alcohol withdrawal , during your previous attempts to stop drinking, then you have a greater risk of delirium tremens. Second, if you resumed after an unsuccessful alcohol self-detox, then your alcohol addiction has probably worsened. You definitely are more physically dependent on alcohol. This makes it both harder and more dangerous to attempt to stop on your own. The consequences of kindling can increase the severity of alcohol withdrawal. Third, if you failed at self-detox in the past, you probably have not corrected any contributing issues. For example, if you are trying to remain sober but you still live with an actively-alcoholic spouse or partner, YOUR sobriety is in danger.

What’s the Bottom Line about Alcohol Detoxification?

If you or someone you care about has a drinking problem and wants to stop, remember this – alcohol withdrawal syndrome can be extremely dangerous – and even FATAL. For this reason, an alcoholic should NEVER abruptly quit drinking on their own. Alcohol detoxification should ALWAYS be done under the close supervision of qualified medical specialists.